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The Value of Nutrition Obesity Research Centers: As Told by Dr. David Allison

Doctor David B. Allison is the current dean, distinguished professor, and provost professor at the Indiana University School of Public Health-Bloomington. Prior to Indiana University, Allison was a distinguished professor, Quetelet Endowed Professor, and director of the NIH-funded Nutrition Obesity Research Center (NORC) at the University of Alabama at Birmingham (UAB). Allison was appointed director of the NORC in 2003 and served until 2017. Allison has published more than 500 scientific papers with research interests including obesity and nutrition, quantitative genetics, clinical trials, statistical and research methodology, and research rigor and integrity.

According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NORCs are “intended to integrate, coordinate, and foster interdisciplinary basic, clinical, translational, and public health research by a group of established investigators actively conducting programs of important, high-quality research that is related to research specific to NIDDK’s mission.”

There are currently twelve university-based NORCs across the United States from New York to Washington State. These centers are funded by P30 Center Core Grants from the NIDDK to bring together investigators who are conducting research in nutrition and obesity and improve the quality of research by promoting multidisciplinary work and sharing access to specialized technical resources and expertise. These centers allow for cost-effective collaboration between groups of investigators at the same institution. The NORC at UAB currently has 159 investigators from 58 different academic units – a manifestation of the center’s multidisciplinary approach.

Allison’s 14-year appointment as director of UAB’s NORC makes him an ideal individual to speak with about the successes of the initiative since its inception in 1999. Allison was gracious enough to answer several questions about his tenure as director and about NORCs more broadly.

What role do you see NORCs playing on university campuses?

NORCs are enormously helpful, and it is valuable to consider them in a historical context. The first NORC – before they were even called NORCs – was the New York Obesity Research Center at Columbia University and, at the time, Rockefeller University. It was the first and for many years only federally funded obesity research center in the United States. The NIDDK subsequently decided to call all the clinical nutrition research units and obesity nutrition research centers “NORCs,” and there are now twelve under this designation.

The New York center is where I started my career as an obesity researcher during my second postdoc. It was a lot of fun there. The NY Obesity Research Center was the mecca of obesity research. If you were an obesity researcher, and if you wanted to get trained, you knew where the mecca was. If you wanted to make a pilgrimage, you could see what the great leaders of the field were doing. You could go there and meet esteemed individuals such as Ted VanItallie, Xavier Pi-Sunyer, and Steven Heymsfield.

You sort of knew where the leadership was – where the intelligentsia and cognoscenti were. There were certainly other places in the world that were powerhouses in obesity, but in the United States, the NY Obesity Research Center served as a galvanizing force. It also served as a great training ground at the time – and NORCs still do. It is one of the things that makes NORCs special: they are multidisciplinary, and they are focused on a topic.

What you sometimes see in the field of obesity, which is probably true in other fields as well, is that there are a lot of instances of people making mistakes that I refer to as “errors in interdisciplinarity.” This is an error which one makes because one is completely unaware of something that would be basic and fundamental to someone in another discipline – but you as a member of a different discipline aren’t aware of it.

A simple example would be if you are a social scientist and you know that physical activity matters for obesity, and you make an assessment that some program will have an important effect, but you don’t know anything about body mass or energetics. You then project the amount of weight change that could occur because of the physical activity intervention without understanding the physics, the mechanics, or the energetics. This is an error of interdisciplinarity.  We see these things regularly.

When I was “growing up” in the NY Obesity Research Center, these kinds of things would become the fodder of your education as a young person. So if you piped up and raised your hand in a seminar and said, “What about this?” it may reveal that you didn’t understand a basic concept in statistics, psychology, physiology, or anatomy. Then the more senior people around, who were experts in those things, would say to you, “Come on over here, kid, let’s explain to you that’s not how that works.” You got it drilled into your head, an emphasis of interdisciplinarity – the idea of real expertise – and avoiding these simplistic mistakes that you still see so often now in people who are focused on obesity research. That is one very valuable part of it: bringing together an interdisciplinary cadre of experts on the topic who then educate young people to be an expert in a topic, and not just get caught up in their own discipline.

The second thing that is extremely valuable is the idea of the NORC as provocateurs of people’s interests. The total amount of money in the NORCs per se is not much – around $750k/year in direct costs – not much bigger than one or two R01s. What is important is not the total cash value, but the way the value is delivered through a leader on campus, who then uses the funds as a lever, at the right points to provoke activity, and provoke interests.

Years ago, early in the NORC’s history at UAB, it became clear to me that using more invertebrate models for obesity was important, that genomics was upon us, and that we should have people working with Drosophila and C. elegans. I was able to use different pieces of the NORC to provoke that. For example, I would bring in speakers through our seminar series who worked on those topics. We had funding for pilot grants that could be used on that research. There were extra discretionary funds from institutional matching, so I could use those funds to recruit some younger people to work on these topics. All those things came together so that people were writing and getting R01s to do research involving those organisms.

There are other things that are important for the NORC in terms of sense of identity.  People are excited to be at an NORC because they feel that they are at one of “the” places. The dollar amount of the NORC isn’t that great, but the prestige value is high. It serves to create an identity to get people excited – to pull them together to work together on things. Those are some of the big values of the NORCs today.

You were director of the NORC at the University of Alabama at Birmingham for nearly 15 years. How have you seen the effect of NORCs change over that time?

I think we have seen a couple of changes. In general, science has changed, and the NORC science has changed with it. Science has become more molecular, more genetic, and the NORCs keep up with the trends of general science. Other things I have seen in NORCs is this idea of leveraging the amount of money. Not only is the amount of money provided by the direct costs of the NORC not large, especially compared to diabetes centers, cancer centers, and other NIH centers that receive much more than NORCs, but it’s been flatlined for over 20 years. If you compared the NORC funds in real dollars to the dollars from 20 years ago, the current funds are much smaller.

NORCs have become these engines – at their best – where creative leaders use the P30 grants as the nucleating site around which to build other stuff. You go to your institution and get a match in funds, and then you get some T32 grants. You say, “Isn’t this great we have an NORC, so we can do great training. Please give us a postdoctoral and predoctoral T32 in obesity, and then why don’t you give us an R5 to do a national short course in obesity?” … You keep adding those things on. We at UAB were very strong on that. Many other institutions are as well, and that is one way you have seen the NORCs change. They have become these multi-infrastructure grant organizations.

When speaking with other NORC directors and center administrators, what are some of the advances and successes that have stood out to you?

I think probably more than anything, the successes and advances that I hear the NORC directors take the greatest pride in is the young people who they help get started, and that is especially true for those NORCs that go on to get T32s, which many have. How I got my own start was on a T32 while in New York. That is also how I learned to write T32s, by being thrown into it by my old boss at the NORC. He said, “Here’s my old folder. I’m going on a trip out of the country. I will be back after this thing is due. Good luck,” and I said “…okay,” and so I learned how to write a T32 grant.

I think when people are successful in getting those T32 grants, as well as in getting young people involved, however they do it, bringing new people into the field, and helping those new people achieve, it is a great success. You can look at many of us and say that we are products of the NORC systems themselves. Myself, Doctors Dympna Gallagher, Tim Nagy, Barbara Gower, Michael Goran, and many others, are all the products of these centers, brought in as postdocs at the beginning of a center. Many who are NORC directors now got their start there.

How do NORCs help cultivate the future generation of nutrition and obesity researchers?

To reiterate, the interdisciplinarity: training people so they are not just a public health person that says, “Yeah I get it, people, they eat too much and exercise too little, what else do I need to know about obesity. Now I just need to talk about the policies that will make people eat less and exercise more.” Well, maybe it would be good to know a little more than that. NORCs bring up people with a more robust knowledge of this. The NORCs also draw people into the field, give them a sense of identity and belonging and an enthusiasm for being in the field.

You have been critical of the rigor at which obesity and nutrition research is performed. Do you think that NORCs have been able to increase the quality of research in the field?

I think that NORCs do increase the quality of research in the field, and they lead by example. I am critical of the rigor and quality of the research everywhere, including in my own research. That is important for us to do as scientists – to be critical of the rigor and the quality of research – and to make it better. I think there are particular concerns raised in the field of obesity, and some of those concerns in my mind came out in the mid-90s when obesity began to be seen as a public health crisis.

Instead of obesity research being driven to a greater extent by people who were fully involved in it for a long time, and involved with others in getting this interdisciplinary background, it became more that anybody felt that they can jump in. Any economist, any public health official, jumped in with zealous passion, which much of the time wasn’t matched with rigorous background knowledge. This has led to some of the more questionable research we have seen. It’s not everything, but just one factor. NORCs are helping by providing training for people, by putting out good research, and by leading by example.

What are some fond memories from your time at UABs NORC

Well, pulling together on things in general. Part of what makes a great center great is people working together as a center. In fact, one of the things that attracted me to come down to UAB was in fact its centeredness. I had other offers before heading to UAB, and some were at institutions that were more attractive in some ways, but what I liked about UAB and the NORC was the feeling that this was a group of people that worked together, and only a slight exaggeration, but it was a sense of a family. I really liked that. To me, a lot of my fondest memories were pulling together with Tim Nagy, Barbara Gower, José Fernández, Tim Garvey, the late Roland Weinsier, Stephen Barnes, Steve Austad, Kevin Fontaine, Julie Locher, Gary Hunter, and I am sure I’ve missed many important people, but the ability to pull together through tough challenges, working hard, overcoming obstacles – doing things together which none of us could have done alone.

 

This is part two of a two-part interview with Dr. David Allison.

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The Need for Increased Rigor in Obesity and Nutrition Research: A Q&A with Dr. David Allison

Doctor David B. Allison is the current dean, distinguished professor, and provost professor at the Indiana University School of Public Health-Bloomington. Prior to Indiana University, Allison was a distinguished professor, Quetelet Endowed Professor, and director of the NIH-funded Nutrition Obesity Research Center (NORC) at the University of Alabama at Birmingham (UAB). Allison was appointed director of the NORC in 2003 and served until 2017. Allison has published more than 500 scientific papers with research interests including obesity and nutrition, quantitative genetics, clinical trials, statistical and research methodology, and research rigor and integrity.

In addition to his primary appointments, Allison is a co-director for two NIH-funded “Short Courses” on obesity research held in Birmingham, Ala., during the summer. Dr. Allison’s “Short Course on Mathematical Sciences in Obesity Research” is going on its fifth consecutive year, while the “Short Course on Strengthening Causal Inference in Behavioral Obesity Research” is coming up on its fourth consecutive year. These interdisciplinary courses convene a cadre of expert faculty members who teach on various aspects of obesity research, covering economics, epidemiology, statistics, genetics, and much more. These courses are oriented toward investigators who want to increase the rigor in their approach to obesity research, and they bridge various disciplines in which obesity research is performed. Allison took the time to answer a few questions regarding the ability to better approach obesity and nutrition research.

You have noted that the rigor of obesity research has been lacking. Has there been a shift in recent years?

I don’t have unequivocal data as to whether there has been a shift in recent years in obesity research or research overall. I have a hypothesis though, which is when you look within any one journal, research is getting ever more rigorous, whereas when you look across all journals, it may be getting less rigorous because of the influx of new journals.

If you take a journal like the American Journal of Clinical Nutrition, they keep getting more rigorous. That is in part because the editor-in-chief, Dr. Dennis Bier, has a very strong commitment to that, and he has built an associate editorial board who shares the commitment. Meanwhile, other journals keep springing up that are not as rigorous. So for the overall quality of the literature, I am not sure if it is going up or down, since you have these competing factors.

One of the things my colleagues and I are writing a paper on now is the childhood obesity intervention literature, which seems to be particularly susceptible to distortion. We hypothesize that this has to do with feelings of zealousness – the idea that childhood obesity is such a problem and it must be addressed. To come out after an expensive and effortful intervention and say, “Guess what, I did an intervention and it just didn’t work, so let’s move on.” People just don’t want to say that. They want to instead say, “But it must work, we can’t tell people not to do this, especially if we don’t have something better, so let’s twist and bend and ‘find a pony in there’.” We see a lot of “spin” in these things, and that is an area where things seem to have become worse.

What are your suggestions to researchers in the field to increase conscientiousness in limiting and being transparent about shortcomings in the quality of the research produced?

I think there are different aspects to it. Some aspects to it, and perhaps related to what I was saying about the childhood obesity literature, is that people, often again with good intentions, are bending the truth. I think that we need to continually remind ourselves that we are scientists and reflect on why we all got into science in the first place. To be a scientist means to pursue truth through the scientific method. We have to affirm that speaking the unvarnished truth is an uncompromisable imperative. Commitment to one’s identity as a scientist is something to be held dear.

Then, I think there are some things that are more skill-level. Many errors I see – and partially because this is my expertise, so I see what I understand and know about – are statistical errors. One of the challenges is that the norm for many years was, and still is, that many scientists should be able to conduct their own statistical analyses. Physicians are generally not trained with this mentality, because they get very little training in statistics. They accept that they will need to go to a statistician – most at least. Whereas if you are trained in a field like nutrition, psychology, physiology, or biology, you get a PhD in that, and you get one or two statistics courses as you earn your PhD, often taught by that same department. The person who teaches that course tends to not be a professional statistician, but rather a physiologist, biologist, or nutritionist who knows a little statistics. What you are getting is kind of an intelligent amateur who is running the statistics for professional research.

If you think about that – it’s the equivalent of me saying that I need to get a kidney surgery and I say, “Well, I have an anatomy book. I know approximately where my kidneys are. I have a bottle of hand sanitizer. I can get some rubber gloves and a pocket knife, and I can do it myself.” Well, no. Just because you have an anatomy book and you know where the kidneys are and you understand the idea of surgery doesn’t mean you are a professional surgeon, and we wouldn’t have you do it. Why take a different view about statistics? Part of what we are currently exploring, since statisticians are in limited supply, is how we can get more professional statisticians to be involved with more papers, and how can we create a culture and an economic situation that would permit that.

Is there an overreliance on observational research in nutrition/obesity studies? If so, why is this the case?

I think there is sometimes a reliance on observational studies for situations in which they are not what I would call “probative.” For example, you can think, “Well, maybe Pokémon GO is going to reduce obesity levels.” No-one has ever looked at it, so sure, go ahead and do an observational study. Do people who start using Pokémon GO lose weight or gain less weight? And that is fine, there is nothing wrong with that. You might even want to replicate it once or twice. But if you say, “Well, now we’ve done that, so let’s do 20 more of those,” then you need to wonder why you need the next 20. Maybe you need one more to confirm it, but not 20 more. What you see is people not shifting out of the observational and into the experimental when it is called for. For example, breakfast consumption, fruit and vegetable consumption, things like that – when people continue to grind on the observational literature long after it is really useful.

You have noted that you see many errors in obesity and nutrition related meta-analyses. How would you caution investigators in interpreting these papers?

I would say, interpret with a grain of salt, particularly if there isn’t a professional statistician on there. The issue is that there is software out there, where it is seemingly easy. You plug in a few numbers, and it spits out a meta-analysis for you. The problem is, you need to know what numbers to plug in. That is where the problem, the challenge, and the mistakes often occur. Particularly, these mistakes seem to occur around variances. I would caution anybody who is going to do a meta-analysis who thinks, “Oh, meta-analyses are easy. I can just get a grad student to grab some papers, write the numbers down, and plug them in some public software.” I would caution people not to do that, but to have a professional statistician involved.

You have published articles criticizing the statistics and assumptions of various academic papers, resulting in their retractions. Can you theorize why these papers are being published in the first place? What are some mistakes that you see most often?

Why they get published in part is because we don’t really have a good system for vetting papers. Many people seem to think that peer review is that system, but I don’t think it was ever realistic to expect that peer review can be the true gatekeeper of papers and can eliminate all mistakes – or even most mistakes. I think peer review just checks if a paper belongs, and then you receive advice. But the peer reviewers don’t have the time and the ability to go through everything the author and investigator did to see if it is correct. That must fall on the investigators themselves. I think many investigators let a lot slip through – some intentional and some unintentional. I think we need to work on both of those things.

What would you recommend to young researchers in the field of obesity and nutrition who would like to improve their ability to identify poor methods and conclusions?

I would say to take our short courses. Read very widely, including interdisciplinary work. Read some work on the physiology of obesity, the genetics of obesity, engineering approaches, computational approaches, nutritional, psychology, medical, and economic approaches, so that you have a broad base to compare things to. I would say to talk broadly and question everything. Question yourself. Question your own ideas. Those are all important things to do.

 

This is part two of a two-part interview with Dr. David Allison.

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Breastmilk from a Bottle and Obesity Risk

As a new parent you can go no longer than 24 hours without hearing the phrase “Breast is Best.” I know this to be true because I became a parent in June of this year. In the hospital we were offered consults with lactation and had no less than six posters in our room touting the benefits of breastfeeding. As a PhD student I was intrigued by the literature behind these recommendations and eagerly spent multiple late night nursing sessions on my iPad reading the latest research. What I found were some studies finding associations with reduced risk of obesity, and others failing to find this same association (literature). Overall, it was concluded in the previous review that breastfeeding was associated with a reduced risk of obesity.

While this was great news, I could not help but question; was this association because of breastmilk or mode of delivery? Bottle feeding is typically associated with formula feeding but a growing number of women have begun pumping their breastmilk after returning to work or in cases of pre-term birth and latch issues.

Could bottle feeding breastmilk still ameliorate the risk of obesity later in life?

I was not the first person to raise this question which has been addressed here, here, here, and here. Overall the consensus seems to be that early bottle feeding, of breastmilk or formula, is associated with an increased risk for excess weight gain and poor self regulation. Exclusively feeding expressed milk is also associated with early cessation of breast-milk feeding.

So this leads to the inevitable question; what is a mother to do?

While the literature is still unclear if bottled breastmilk can fight obesity risk, it is clear the breastmilk has multiple other benefits according to the American Academy of Pediatrics and should be offered when possible. So to those mothers who pump a little, a lot, or all the time, I say pump on ladies!

The Future of the National School Lunch Program

The former First Lady Michelle Obama revealed her “Let’s Move!” campaign in February of 2010 with the intent of curbing the childhood obesity epidemic. The initiative included a modification to the nutrition standards of the U.S Department of Agriculture’s (USDA) National School Lunch and School Breakfast Programs which provide 32 million meals to children daily. The principle legislation effecting these standards is the Healthy Hunger-Free Kids Act (HHFKA) of 2010 which has been touted as the first major reform to school lunch and breakfast in nearly 30 years.

In accordance with recommendations from the Institute of Medicine report “Nutrition Standards for Foods in Schools: Leading the Way toward Healthier Youth” and the 2010 Dietary Guidelines for Americans, the HHFKA informs the nutrition guidelines that schools must follow in order to be eligible for reimbursement under the National School Lunch Act and the Child Nutrition Act. Various standards resulting from the HHFKA went into effect in 2012, requiring schools to serve more fruits and vegetables, limit sodium, increase the whole grain composition of foods, and increase low-fat and non-fat options. To be more precise, all grains must be 50% whole grain by weight (or have whole grains as the first ingredient), food items can’t have more than 35% of total calories coming from fat, and only 10% of total calories can come from saturated fat. Many exceptions to these regulations exist and are enumerated in the final rule, which codifies the Act. For example, a high-fat food like peanut butter can be served if it is paired with a vegetable or fruit.

A 2014 study evaluated the initial implementation of the HHFKA in a cohort of students at four elementary schools in Washington State. The new guidelines were adhered to by 2013, and compared to the prior year, there was a decrease in average caloric intake by students across each individual macronutrient. Ingestion of key nutrients such as calcium and vitamin C decreased compared to the meals consumed under the old guidelines. Fiber was the only nutrient that was significantly increased. Despite the general dietary improvements that resulted, only about 1,000 meals in total were examined in this study. Following the implementation of these guidelines, childhood obesity rates have remained rather stable, but extrapolating the impact of this program on obesity rates over such a short time interval would not be sensible.

The new secretary of the USDA, Sonny Perdue, announced this past week that schools will be given “greater flexibility in their nutrition requirements for school meal programs in order to make food choices both healthful and appealing to students”. Schools have been facing increased financial burdens by adhering to the HHFKA regulations alongside a decline in school lunch participation, further exacerbating financial strain. Though students may be foregoing school lunches more often, the levels of food waste have not significantly changed compared to pre-implementation. Secretary Perdue acknowledged that 99% of the schools are partially compliant with the HHFKA standards, but noted that this metric is not indicative of program success. The temporary flexibility granted by Secretary Perdue includes a sodium target that is less rigorous, an exemption of the required 51% whole-grain composition, and the ability to serve 1% flavored milk rather than strictly non-fat flavored milks.

Dr. Margo Wootan of the Center for Science in the Public Interest, a consumer advocacy group, expressed disconcert with Secretary Perdue’s regulatory roll back, stating that “ninety percent of American kids eat too much sodium every day” and that “schools have been moving in the right direction, so it makes no sense to freeze that progress in its tracks.” Conversely, the School Nutrition Association, a nonprofit with 57,000 members, applauded this reform in a press release citing the HHFKA regulations as “overly prescriptive and having resulted in unintended consequences including reduced student participation, high costs, and food waste.” The new flexibility emphasizes the authority granted to localities to bolster the requirements of their own school nutrition and physical activity through the use of local “wellness policies.” The temporary deregulation of the HHFKA lowers the proverbial “floor” set by the federal government, giving the states an opportunity to have a direct impact in fighting the obesity epidemic.

References
https://www.fns.usda.gov/school-meals/healthy-hunger-free-kids-act
https://www.federalregister.gov/documents/2012/01/26/2012-1010/nutrition-standards-in-the-national-school-lunch-and-school-breakfast-programs
https://schoolnutrition.org/uploadedFiles/About_School_Meals/What_We_Do/Nutrition%20Standards%20for%20School%20Meals.pdf
https://www.cdc.gov/obesity/data/childhood.html
http://stateofobesity.org/childhood-obesity-trends
https://www.usda.gov/media/press-releases/2017/05/01/ag-secretary-perdue-moves-make-school-meals-great-again
https://schoolnutrition.org/news-publications/press-releases/sna-commends-usda-supporting-practical-flexibility-benefit-school-meal-programs/
https://www.cdc.gov/healthyschools/npao/wellness.htm
https://cspinet.org/news/trump-administration-undermining-school-meals-menu-labeling-20170501
https://www.ncbi.nlm.nih.gov/pubmed/24650841

At What Point Do We Enact Obesity-Targeting Policies?

How much evidence should be demonstrated before enacting obesity-targeted health policy? This difficult question was debated between two speakers Sunday at ASN’s Scientific Sessions and Annual Meeting, as part of the Obesity Research Interest Section Forum, chaired by Andrew Brown, PhD.

The first speaker, Laura Schmidt, PhD, defended the need to set such policies early on. According to Schmidt, one reason we cannot afford to wait for perfect evidence is because the National Nutrition Research Roadmap indicated that the average amount of time that it takes for research to go from bench to bedside/community is 17 years. Dr. Schmidt noted that how research is translated to policy needs to be strategic and carefully considered, the evidence must be robust and systematically reviewed, but that science can only inform, not drive policy decisions. Often it is not possible to enact policy at exactly the specifications that research suggests. For example, a 20% tax on sugar sweetened beverages was indicated to show an effect on sales, but San Francisco couldn’t get a bill passed into law until the tax was reduced below 20%. Standards for evidence are often higher in the scientific community, she said: they utilize systematic reviews, expert panel summaries, and formal guidelines by federal and global agencies. When the results of a large number of different types of studies that use different measures and outcomes point in the same direction (i.e. observational, clinical trials, and mechanistic), we can be confident in the strength of the evidence. Schmidt gave an example of some issues she perceives haven’t reached a body of research big enough to act on yet: taxing 100% juice or diet sodas, even though there is emerging concern on each from the literature. Finally, Dr. Schmidt noted that we need to be concerned with industry funded research as some evidence suggests it may bias conclusions on a topic. To summarize: we should acknowledge the need to translate research in ways that can inform policy and that best practices and standards for evidence-to-policy are shaping up, but that challenges remain, including scientific bias due to conflicts of interest.

As a contrasting perspective, Michael Marlow, PhD, outlined his concerns with setting policies without a very high level of confidence that they will succeed. In other words, caution must be exercised because researchers don’t yet know optimal policies. He outlined his concerns as follows: 1) There are good intentioned hunches over scientific exploration. Confirmation bias and common narratives may lead to policies that don’t reflect reality. 2) Many research methods promote type-I errors, such as P-hacking, often a consequence of tenure and grant requirements and journal editor demands. 3) The quality of dietary data is poor. Dr. Marlow pointed to a study that found that for 95% of a study sample, fast food, soft drinks, and candy had no association with BMI. There are a number of possible interpretations to this: the data sources (diet recalls) may be so seriously flawed that it is ok to advocate laws that only affect 5% of the population. Should we enact policy or wait until data collection is improved? And, 4) There is naive modeling of interventions that goes into estimating policy efficacy. Linear relationships are often assumed between availability of nutrition information and behavioral changes, for instance. Because of what is overlooked, Marlow’s simulations of policy success range from 6.25% with optimistic probabilities of effects to 0.01% with less optimistic assumptions. To summarize: policy proposals need solid theoretical and empirical support, data quality needs more attention and acknowledgement, measures for policy success need major rethinking, uncertainty and unintended effects need acknowledgment, and we need to resist ill-advised albeit good-intentioned policies from citizen pressure.

There is no easy answer to how long we should wait before enacting health policies that target obesity. Translating research to policy is difficult and policy as a natural experiment can help us understand if we can impact obesity. A common thread of agreement is the need to ensure that we have high quality research methods and to reduce bias wherever possible. Perhaps then the question would be easier to answer.

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Health Professionals Need More Nutrition Education. How Can We Deliver?

By Allison Dostal, PhD

It’s not a revelation that most Americans would benefit from increased nutrition education and guidance. Newly released data from the Centers for Disease Control and Prevention1 show that 64% of Americans are overweight or obese – a number that’s held steady over the past few decades – and that nearly 40% of us consume less than 1 serving of fruits or vegetables daily. $210 billion is spent annually on obesity-related disease2.

It is known, perhaps intuitively, that physicians trained in nutrition achieve improved health outcomes in patients with obesity-related conditions3. Numerous clinical guidelines recommend that physicians counsel their overweight and obese patients on diet, and yet, fewer than 25% feel that they received adequate training in doing so. As a result, only 1 in 8 medical visits includes a discussion of nutrition4,5. This disconnect in recommendations versus practice is a significant issue in medical education today, and the perennial discussion of how to improve the current state of nutrition education in the medical curriculum continues to increase in relevance in our nation’s obesity crisis.

The Problem

It is recommended that physicians-in-training receive 25 contact hours of nutrition education, including basic nutrition knowledge, assessment, nutrition intervention, and dietary treatment of disease. However, nutrition education in medical schools has continued to fall below this target – and it’s getting worse. A 2012 survey4 found that most medical schools fail to require the recommended amount of nutrition education, with less than 15% of schools providing the 25-hour minimum. The number of hours devoted to nutrition education has dropped substantially since 2004, while the number of schools with no required nutrition education has risen4.

Compounding this issue, many medical training programs provide only basic nutrition background, often buried within a biochemistry or physiology course. While it is undeniably important to highlight the specific actions of vitamins and minerals, this model fails to highlight real-world clinical application of nutrition. Even less time is devoted to developing patient counseling skills. Lastly, the U.S.’s health professional training systems do not provide expertise or incentives to deliver effective counseling on how to achieve and maintain a healthy weight, diet, and physical activity level. This leads to a divide in thinking – a “should” or “want to do” versus “need to” or “have time to do”, and a reduced sense of urgency about implementing changes.

Working Toward a Solution

In addition to a lack of monetary or standard-of-care incentive to increase knowledge dissemination, another primary reason for suboptimal nutrition education is lack of time. This exists both in the amount of time devoted to actual coursework within medical training and for development of a nutrition curriculum within a program. Fortunately, several groups have worked diligently to provide resources that alleviate these barriers. In contrast to many programs that are specific to a particular institution, Nutrition in Medicine6, is a web-based series for students and healthcare professionals, administered through the University of North Carolina at Chapel Hill’s Department of Nutrition. There are over 40 modules ranging from 15 to 60 minutes in length that offer basic nutrition knowledge as well as evidence-based instruction of clinical skills. In addition to providing biochemical, clinical, and epidemiological components and virtual case studies, NIM also offers nutrition tools like pocket notes, nutrient recommendations, quizzes, and YouTube video vignettes. Nearly 75% of U.S. medical schools take advantage of at least one NIM module, and the program has proven to be successful in providing 33% more nutrition education in schools that use NIM versus those that do not.

And the best part? It’s completely free.

Future Directions

Despite the advances made by NIM in improving the dissemination of nutrition knowledge in the medical curriculum, challenges remain. Martin Kohlmeier, NIM’s principal investigator, has acknowledged that building good nutrition education tools is expensive and time consuming, since materials need to be reviewed continuously and updated every 4-5 years. Supporting a web-based tool takes a significant amount of resources, and funding sources are difficult to consistently maintain.

Recently, this cause has been taken up by several prominent health and medicine-focused organizations. A new effort has been launched to teach medical students, physicians, and other allied health professionals how to discuss obesity treatment and prevention options with patients. This initiative is a collaboration between the Bipartisan Policy Center, the Health and Medicine Division of the National Academies of Sciences, the American College of Sports Medicine, and the Alliance for a Healthier Generation. The multi-year project, supported by the Robert Wood Johnson Foundation, will develop “core competencies for obesity prevention, management, and treatment for the health professional training pipeline and identify payment policies that will incentivize the delivery of this care”, as stated in their April 11th press release7. Their goals are for these competencies to be implemented in training programs across the full spectrum of health professionals, and to determine a strategy to reimburse effective counseling for maintaining a healthy weight, diet, and physical activity level. “Training health professionals without a concurrent strategy to reimburse this type of care will not lead to meaningful change. And offering payment without having trained professionals to provide the care also will not result in improve[d] patient care,” the group stated.

This working group, like those involved in the Nutrition in Medicine curriculum, acknowledges that systemic changes to improve nutrition education in medical training will require continuous commitment from a wide range of stakeholders. Details of this initiative have not yet been announced, but those of us involved in education and clinical care certainly look forward to seeing the first steps begin.

Are you a health care professional, student, or educator? What is your experience in teaching or learning nutrition and nutrition counseling skills? I welcome your comments and insight on this issue.

References

1.Nutrition, Physical Activity and Obesity Data, Trends and Maps web site. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity and Obesity, Atlanta, GA, 2015. Available at http://www.cdc.gov/nccdphp/DNPAO/index.html.

2.Cawley J and Meyerhoefer C. The Medical Care Costs of Obesity: An Instrumental Variables Approach. Journal of Health Economics, 31(1): 219-230, 2012.

3.Rosen BS, Maddox PJ, Ray N. A position paper on how cost and quality reforms are changing healthcare in America: focus on nutrition. Journal of Parenteral and Enteral Nutrition 2013;37(6):796–801.

4.Adams, K.M., Kohlmeier, M., & Zeisel, S.H. Nutrition Education in U.S. Medical Schools: Latest Update of a National Survey. Academic Medicine. 2010;85(9): 1537-1542.

5.Early KB, Adams KM, Kohlmeier M. Analysis of Nutrition Education in Osteopathic Medical Schools. Journal of Biomedical Education, vol. 2015, Article ID 376041, 6 pages, 2015. doi:10.1155/2015/376041

6.K. M.Adams, M.Kohlmeier, M. Powell, and S. H. Zeisel, “Nutrition in medicine: nutrition education for medical students and residents. Nutrition in Clinical Practice. 2010;25(5), 471–480. Available at: http://nutritioninmedicine.org/

7.Bipartisan Policy Center. New Effort Launch to Train Health Professionals in Nutrition and Physical Activity. http://bipartisanpolicy.org. 21 Mar. 2016.

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Obesity is Not a Disease of Sloth and Gluttony

By Caitlin Dow, PhD

The most recent data from the CDC indicates that approximately 35% of American adults have obesity (1). In order to reduce obesity prevalence, a popular notion is that people with obesity just need to “eat less and move more.” Indeed, many public health programs use this concept as their primary approach for combating obesity. While eating less and moving more may help prevent obesity or result in successful, sustained weight loss in individuals who are simply overweight (but not yet obese), ongoing research indicates that these simple lifestyle changes will do very little in the face of prolonged obesity (2).

If you look at any weight loss study, you will most assuredly find the same results, regardless of study design. The first six months are generally characterized by substantial weight loss, followed by sustained weight regain, resulting in a final weight that is negligibly lower and potentially higher than the starting weight . This “checkmark effect” or weight loss recidivism that has been reported nearly ubiquitously across diet and exercise-based weight loss trials (3) indicates that lifestyle interventions are generally not successful modalities for treating obesity.

Based on a rudimentary understanding of metabolism, the calories in/out approach should work for weight loss and weight loss maintenance. So why doesn’t it work for so many people? The answer lies in the complex network linking the environment, genetic predisposition to obesity, as well as metabolic and physiological changes. A large body of literature indicates that the brain’s reward systems are significantly dysregulated in individuals with obesity (4). In an environment that supports ease of access to highly palatable foods, the pleasurable effects of consuming said foods can override homeostatic control of intake. While some people are able to regulate intake despite the high palatability of these foods, a number of genetic mutations in the brain’s reward systems may result in overeating and obesity in many people. Furthermore, the hypersensitive reward systems that often lead to obesity can become insensitive once a state of obesity is attained. In effect, this leads to overeating to receive the same pleasure from the same foods. These dysregulated reward systems are coupled with preadipocyte expansion into mature adipocytes, allowing for increased fat storage. While this isn’t the entire story, this should shed some light on the complex interactions of dysregulated internal systems that foster the metabolic abnormalities that result in obesity. Importantly though, these impairments are typically only demonstrated once obesity has been introduced and sustained (3).

As for weight loss, when caloric restriction is initiated, the body triggers a number of systems to prevent starvation. From an evolutionary perspective, this makes sense as food sources were often unpredictable and the body adapted to conserve energy – the “feast and famine” principle. However, for most of us living in industrialized nations, famine is rare and feast is common, limiting the need for this once very necessary adaptation (though the body has not evolved to recognize the abundance of calories in our modern food supply). When we try to induce weight loss via caloric restriction, the body will reduce its resting metabolic rate to counter these advances (5). This supports the “set point theory” – the idea that the body will defend its highest-sustained weight. In fact, as weight loss increases, the drive to restore the highest bodyweight only increases (6). It’s like when you’re pulling on your dog’s leash to get him into the vet and he plants his feet firmly and resists with all his might. Ultimately his strength pulls him out of his collar and sends him running in the opposite direction. Except here we’re talking about the human body and it’s not nearly as comical.

All of these biological adaptations that introduce, sustain, and defend obesity explain why weight loss and its maintenance is so exhaustingly difficult for so many people. As Ochner and colleagues suggest, most individuals who had obesity but lost weight simply have “obesity in remission and are biologically very different from individuals of the same age, sex, and body weight who never had obesity.” As a hypothetical scenario, imagine you are comparing two people: they weigh the same, but person A had obesity and has lost weight whereas person B has never lost weight. Person A will have to burn up to 300 calories more (or consume 300 calories fewer) than person B to maintain that weight (2). This underscores the idea that weight regain is not simply an issue of willpower and weakness.

What we need more of are studies evaluating multiple approaches to weight loss (surgeries, medications, likely in combination with lifestyle changes). What we need less of is bias from people without obesity, the media, and even healthcare providers. Indeed, “the mere recommendation to avoid calorically dense foods might be no more effective for the typical patient seeking weight reduction than would be a recommendation to avoid sharp objects for someone bleeding profusely” (2). We also need better obesity prevention approaches because, clearly, it’s biologically more feasible to prevent weight gain than to lose weight and keep it off.

References

1.Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adults obesity in the United States, 2011-2012. JAMA. 2014;311(8):806-814. doi:10.1001/jama.2014.732.

2.Ochner CN, Tsai AG, Kushner RF, Wadden TA. Treating obesity seriously: when recommendations for lifestyle change confront biological adaptations. Lancet Diabetes Endocrinol. 2015:

3.Ochner CN, Barrios DM, Lee CD, Pi-Sunyer FX. Biological mechanisms that promote weight regain following weight loss in obese humans. Physiol Behav. 2013:120:106-13. doi: 10.1016/j.physbeh.2013.07.009.

4.Kenny JP. Reward mechanisms in obesity: new insights and future directions. Neuron. 2011:69(4):664-79. doi:10.1016/j.neuron.2011.02.016

5.Grattan BJ, Connolly-Schoonen J. Addressing Weight Loss Recidivism: A Clinical Focus on Metabolic Rate and the Psychological Aspects of Obesity. ISNR Obesity. 2012. doi:10.5402/2012/567530

6.Rosenbaum M, Leibel RL. Adaptive thermogenesis in humans. Int J Obes.2010:34:S47-55. doi:10.1038/ijo.2010.184

ACCN15: Navigating the New Obesity Guidelines and Algorithms

By Celez Suratos, MS, RD, ACCN15 Blogger

It’s no surprise that obesity was one of the many topics covered at the recent Advances and Controversies in Clinical Nutrition (ACCN) conference. At his presentation during ACCN, Dr. Scott I. Kahan, MD, MPH, delved into the many obesity guidelines and algorithms that exist today.

According to Dr. Kahan and the National Guidelines Clearinghouse, there are over 400 guidelines on the topic of obesity (this excludes the number of other various topics that may include obesity as secondary information). With an ongoing and growing list of information on obesity, how does a clinician sift through it all to find a best strategy to put into practice? Luckily Dr. Kahan summarized four recently published guidelines that can help anyone interested in knowing more about how obesity should be approached from a treatment standpoint. These guidelines were derived from the (1) National Heart, Lung, and Blood Institute (NHLBI); (2) Endocrine Society; (3) American Association of Clinical Endocrinologists (AACE); and (4) American Society of Bariatric Physicians (ASBP).

The information shared in this post will be from Dr. Kahan’s summary of the guidelines from the NHLBI. The recommendations derived from this organization attempt to answer questions regarding the benefits of weight loss, risk of being overweight, the ideal diet an obese individual should follow, what lifestyle interventions are relevant to assist obese patients achieve and maintain weight loss, and the any benefits or risks of bariatric surgery, if such an intervention is necessary. The five recommendations a practitioner should follow when treating the obese patient include:

– Use body mass index (BMI) as the primary screening tool to identify patients who are obese (currently defined as BMI greater than 30). One should also consider waist circumference as a secondary screening tool to identify patients who may be at increased risk for cardiovascular disease
– Advise on moderate weight loss, as defined by a three to five percent reduction in weight, rather than a goal weight. Three to five percent may sound like such a small amount, but it can still have a great impact on various health outcomes in an obese individual. And it may be a less daunting goal for the patient
– Just like a magic pill to make a person instantly lose weight overnight does not exist, there is no such thing as the perfect diet prescription to guarantee sustained weight loss. The focus should be on an individualized meal plan that is lower in calories, incorporates the patient’s food preferences (to encourage compliance), and is used in conjunction with modified lifestyle behaviors
– A successful intervention requires a multidisciplinary approach inclusive of professionals from the fields of nutrition, physical activity, and behavior modification that proceeds for at least six months. According to the data included in Dr. Kahan’s presentation, during this comprehensive intervention period, patients with frequent on-site counseling exhibited more weight loss than patients who relied on other forms of counseling (i.e. electronic counseling, counseling through more commercial weight loss programs)
– The last recommendation from the NHLBI guidelines involves bariatric surgery when appropriate. At present time, patients with BMI greater or equal to 40 kilograms (kg)/meter (m)2 or greater or equal to 35 kg/m2 with co-morbidities, bariatric surgery may be a more viable option than the other previously mentioned recommendations.

Weight loss is not a “one size fits all” scenario; it is always best practice to individualize, individualize, individualize! Obesity is a complex issue that involves more than just number of calories, or those seen on a weighing scale. It is a disease state that constantly relies on a collaborative approach from experts in multiple health-related disciples in order to ensure the best results.

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ACCN15: Motivational Interviewing Techniques to Encourage Lifestyle Changes/Weight Loss

By Celez Suratos, MS, RD, ACCN15 Blogger

Motivational interviewing (MI) is a technique used to incite positive behavior change. It is directive and client/patient-centered. Healthcare providers (including registered nurses and dietitians) use MI to direct self-motivational statements from the patient. Hence, allowing patients to be in charge of setting and meeting their own goals. Dr. Kathryn I. Pollack from the Duke University School of Medicine facilitated an interactive workshop on MI at this year’s Advances and Controversies in Clinical Nutrition Conference (ACCN). The main focus was to inform healthcare providers of the “spirit” of MI, as well as putting MI techniques into practice through role-playing.

Most of us are familiar with the phrase, “it’s not what you say, it’s how you say it.” But did you know that communication is approximately 90 percent body language? MI is more than a methodological counseling approach. It also causes a healthcare provider be more present and aware of how he/she is communicating to the patient. According to Dr. Pollack, the “spirit” of MI embodies four key principles to elaborate on such a concept; Partnership, Acceptance, Evocation, and Compassion.

A healthcare provider may have the tendency to dominate the conversation by supplying the patient with numerous facts about the status of his/her health, likely telling the patient what he/she “must” do in order to prevent the “worst-case scenario” from happening to them. However, in MI, a provider should focus on building a partnership-like relationship rather than one that is hierarchical. One can do this by initially asking permission before sharing information and giving advice. This allows patients a choice to discuss their health based on their own readiness to handle the information you want to give them. Alternatively, a provider can ask the patient what concerns he/she may have in order to allow the patient to set the agenda, giving the patient the power to discuss what he/she may already be thinking about improving.

Acceptance goes beyond the concept of non-judgment. This means the healthcare provider accepts the patient’s motivation, commitment, and choices in totality. This relates back to non-verbal communication. If you are feeling judgment, you are also likely exhibiting judgment, which then means your patient can see your judgment. Think about it – do you ever cross your arms or furrow your brow when you disagree with a statement? Letting go of judgment will not only improve your skills as a practitioner, but can be freeing as well.

A healthcare provider may be able to provide a patient with beneficial reasons to improve his/her health status. However, evocation is the idea that people are motivated by their own reasons. In MI, the provider facilitates a conversation that allows the patient to find his or her own motivation for adopting positive change. One way to help patients find their motivation is to prompt them with questions to discuss their readiness to change. Such questions may include asking patients to rank their readiness to change (i.e., on a scale of 1 to 7 –with 1 being least ready to change and 7 being most ready for change, for example), then asking why they chose that particular number on the scale, what it would take for them to rank their readiness for change even higher (if not already ranked as a priority), and when will they be ready to implement their plan. Evocation extracts information from the patient, such as reasons to change, identifies barriers to change, and eventually a self-actualized plan to get patients to reach their goal(s).

Dr. Pollack also mentioned ‘compassion’ as a novel principle to the spirit of MI, particularly in the provider-patient relationship. It comes from the idea that providers should use open-ended questions, reflective statements, and summarize the conversation when they interact with their patients. This demonstrates active listening, versus a series of agreeable head-nods or dismissive “uh huh” verbal responses. Compassion also calls on providers to give patients affirmation with each step they take to reach their goal(s), even during times of perceived setbacks.

Dr. Pollack summarized that only the patient can make change happen for him or herself. The patient is the one who needs to put in the work to see results. Motivational interviewing is not only a tool healthcare providers can use as a catalyst for positive change, but is also a specific skill that takes practice and time to perfect.

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Rethinking the problem of long-term weight management

By Banaz Al-khalidi

Losing weight is hard enough. Keeping it off is even harder. Despite decades of scientific advancement in our understanding of energy intake and energy expenditure, weight regain after weight loss remains a major issue in obesity treatment. What could we be missing in this energy balance equation? Rethinking this problem, I think it is worth asking ourselves whether we live to eat or eat to live. There is a huge difference. Given the abundance of food in our environment, the majority of us will live to eat. But what drives this motivation or simply put, what are the determinants of healthy versus unhealthy behaviors?

Generally, healthy lifestyle interventions including diet, exercise, and behavioral strategies, such as keeping a food log, have proven to be effective for weight loss in the short term. However, participants’ lack of adherence to the intervention coupled with subsistence of unhealthy behaviors result in weight regain in the long term. According to a research on cardiovascular health behaviors and health factor changes in the US population from 1988 to 2008, healthy diet scores changed minimally (from 0.3% to 1.4% between 1999 and 2008), and physical inactivity levels decreased by only 7-10% from 1999 to 2006. Furthermore, by 2020, it is estimated that 43% of American men and 42% of American women will have a BMI of ≥ 30 kg/m2 (i.e., obese category). Despite the established risks and benefits associated with diet and physical activity, it seems that health behaviors tend to be incredibly resistant to change.

A recent report from a panel of obesity experts convened at the National Institutes of Health discussed the issue of weight regain after weight loss. The authors highlighted the problem of behavioral fatigue, in which patients grow weary of strict lifestyle regimens, especially when weight loss declines after the first 6 months. Specifically, the authors mentioned that “Initially, the positive consequences of weight loss (e.g., sense of accomplishment, better fit of clothes) outweigh the cognitive and the physical effort needed to lose the weight. Later, when the goal is to maintain lost weight, the positive feedback is less compared to the effort required to keep adhering to the same regimen. Thus, the benefits no longer seem to justify the costs”. In other words, the costs of adherence to these interventions exceed the benefits as time progresses, and patients seem to justify their behavior by re-thinking about the cost/benefit ratio in the long run. How can we then increase the long-term benefits while decrease the costs associated with weight maintenance?

There is a need to understand what factors allow people to successfully maintain a behavior over a long period of time. In recent years, obesity and behavioral scientists have started to explore strategies that involve incorporating ‘mindfulness’ to promote the sustainability of healthy behaviors. Mindfulness is defined as: awareness of the present moment, and paying attention to one’s moment-to-moment experiences non-judgmentally. This attention leads to a clear awareness of one’s own thoughts as well as one’s environment in that one observes what is happening, but instead of reacting, the mind views these thoughts as inconsequential. This does not mean disconnection from life; rather, the mind is actively engaged and flexible. Mindfulness is not a technique but it is a way of being.

You might ask, what does this have to do with obesity and health behaviors? They’re all related. Mindfulness-based interventions (MBIs) have recently become a focus for the treatment of obesity-related eating behaviors. A recent review paper examined the effectiveness of MBIs for changing obesity-related eating behaviors. Of the 21 studies included in the review, 18 studies reported positive results for obesity related eating behavior outcomes. Specifically, mindfulness enhanced self-awareness and self-regulation (i.e. long lasting self-motivation) by improving awareness of emotional and sensory cues, which may be effective for sustaining a behavior in the long term. It’s about acceptance of the moment we’re in and feeling whatever we feel (accepting both positive and negative emotions) without trying to resist, change or control it. Under emotional stress, most of us will try to comfort ourselves by putting something into our mouths, but being aware of the negative emotions, and having greater self-control skills may help us resist the urge to eat large quantities of food or unhealthy food. Thus, greater awareness and self-control skills may help an individual to better monitor and regulate their dietary intake as well as their engagement in physical activity.

When we live to eat, we tend to engage in the act of mindless eating because we tend to see food as a source of reward or entertainment, and we shovel food into our mouths without paying attention to what we’re eating and whether we feel full. However, when we’re more mindful or self-aware (i.e. eating to live), we become more conscious of what goes into our bodies by focusing fully on the act of eating and eating related decisions. The bottom line is mindfulness may help patients identify internal and external eating cues, manage food cravings, and enhance self-regulation and resilience- all factors important to counteract the behavioral fatigue that tends to occur in lifestyle interventions over time. Perhaps, when we’re more mindful, we’ll tune into our bodies instead of our thoughts (i.e., thinking about the costs/benefits), and will start to look at food as nourishment rather than as emotional comfort blanket. It is important to note that research in this area is still preliminary but exploring and understanding the relationship between mindfulness and health behaviors may hold promise for long-term weight management.